If this were a bookstore, you would read the back of the book-decide to buy. Find this on Amazon at https://goo.gl/PGTW30

UPDATE: as of February 3rd, 2015, this entry has 38,633 (thirtyeight thousand, six hundred and thirty three) separate views. It’s the single most popular blog entry I have written. Please feel free to add your feedback and comments.

Disclaimer: I myself went to grad school fairly early in my career – after just one year as an RN. In those days (the 1970s) the federal government supported nursing education with generous grants and stipends which we knew would not last forever. I did not incur any debt for grad school, whatsoever. sweet! I continued to work as an RN after grad school, and the MS credential surely came in handy when I finally needed to have it. So – I am in favor of graduate education.

Buzzwords. The Trend Du Jour.

Advanced Practice Nursing is a big buzzword nowadays and we are using the idea of it to attract people to the nursing profession. Throughout the USA there is a proliferation of “three-year’s wonder” programs, the idea being that the student does an entire nursing program the first year, then takes NCLEX, then spend two more years getting their MSN and NP while they work part-time as an RN. It’s particularly attractive during the down economy we are experiencing, because there are plenty of people out there with prior BS degrees who are looking for a fulfilling job. It is oh-so-seductive to think they can gain the RN skill in just one year.

Okay, so it’s a wave – lots of schools and universities are offering these programs. there are plenty of stats to provide a rationale for the career track we are inventing.

The aging of the population

The lack of Medical Doctors to provide primary care

the overall need for RNs to replace the RNs in the baby boom who will be retiring soon.

etc etc etc

I am not disputing those trends, but I am bemoaning some things that seem to be getting lost along the way.

To begin with, role socialization into nursing goes out the window when the time is compressed. Many of the persons who come from these programs seem to me to be unaware of how nurses work as a team, how nurses work in a hospital, and how to do any kind of personal care for a sick person. In other words, such things as cleaning up “fecal incontinence.” When this comes up in conversation, they say “oh, well, I am going to be a nurse practitioner and I will be in an independent practice, I don’t need to learn those things.”

Oh Really?

My retort would be: If You are hoping to get a part-time nursing job to put yourself through school while you get the next two years of grad school under your belt, you will be judged according to the standard of the nurses around you, not to the other standard. It is extremely unlikely that you will be getting anything other than a staff nurse job while you work during school.

also, don’t discount what a staff nurse learns. accountability and integrity are a big piece of the socialization process. A staff nurse in a labor-intensive setting like a hospital, gets daily role modeling from the older nurses. daily mentoring. any new nurse needs to develop trust with those already in the setting, and people will trust you more if you aren’t afraid to get your (gloved) hands dirty.

Think about this: if a patient has been incontinent of feces, no real nurse ever just lets them lay there. Never ever. You may not have to clean them yourself, but you do need to know how. Being clean is a critical element in the dignity of human beings. a very simple precept, really….. and if you as a student disrespect this, you will not gain the trust of the nurses around you.

Myth Two – independent practice

The next myth for Advanced Practice is that “I will be in an independent practice and I am not going to need to learn to work in the kind of subservient hierarchy that a traditional staff nurse needs to navigate through”

If that is truly the case, you will need to borrow money to rent office space, hire a billing agency, advertise to the community, all those things just like you were opening up a furniture store. Ask yourself if you have the business skills to do it, or to get a loan. There are some great resources out there, I particularly recommend one book by Carolyn Buppert; but – is that what you want to do? Most Medical Doctors gave that up twenty years ago, the hassle of “hanging out a shingle” was way too much. We are training you to provide population-based care, which means many of you will be making frequent rounds in a Long Term Care Facility, as part of a group practice. The retired frail elderly population of USA is burgeoning, right? your job will consist of freeing up time for the doc you work with so they can focus more on the technical side.

The small population of ARNPs who will be doing more acute care will be drawn from among those nurses who went the hospital- nursing route and solidified their skills before they enrolled in NP school.

let’s reserve the topic of subservience for some future blog, shall we?

Myth Three

I will be making a lot more money than a staff nurse

In many states the recertification requirement for any ARNP is 40 to 80 hours per year. If you maintain dual-certification, you may have more. This works out to ten working days per year where you are in classes (or being online). When you are in class, you are not seeing patients, and your income is affected. You will also have to pay higher malpractice costs. If you are in a family specialty, you will have many patients who don’t have insurance. All these things detract from the bottom line.

Myth Four

If it doesn’t work out, I can always fall back on a job as a faculty member somewhere.

Yes, we do have a shortage of nursing faculty. and the minimal requirement to teach is a Master’s Degree. This is one that puzzles me. For years now there has been such emphasis on going the NP route, that very few nurses enroll in an education track for graduate school. The result? a shortage of faculty, now being filled by recruiting from among those Master’s Prepared nurses who are unsatisfied with an NP job, and who get hired to teach.

There is a problem with this. A converted-over NP with a MS degree does not automatically have the clinical knowledge base to teach in an inpatient clinical setting; and they also don’t have any course work in pedagogy, the science of teaching, how to lecture, how to construct a valid exam, none of the things an educator needs to know in order to be effective.

So far this trend has been under the radar. Any school of nursing where the administration is addressing this, will be ahead of the game.

So, what you have just read was a “rant” – the kind of complaining I always dislike. If I were to stand up at a professional meeting, I am sure there would be a pregnant pause when I was done. People would look around the room, and then some sweet and wise person would bravely ask And what do you propose that we do about this?

My answer would be:

for the student: realize that you are entering a profession with a long history of service and where you will learn from all those around you in any setting you enter. The more responsibility you are given, the more direct (and sometimes brutal) the feedback will be.

study the idea of role socialization. don’t let it be a hit-or-miss proposition. realize that your thinking style will be changed by becoming a nurse. oh yes it will…..

don’t disrespect the basic skills of personal care. paradoxically, the more likely you are to work in critical care, the more you will need the kind of teamwork and excellent personal care skills you learn at a basic level.

don’t disrespect the work done by staff nurses, whether it is in a hospital, long-term care facility, or other setting. not ever.

for the schools: be realistic when advertising what a fast-track program can provide and how it fits into a clinical track. When a MEPN student is disrespecting the work of staff nurses, call them out.

emphasize the whole role socialization piece. Insist that the skills portion of undergrad curriculum is rigorous and incorporates socialization, not simply mechanical performance.

insist that converted over NPs who take on a faculty role be given the maximum in mentorship

reclaim the nursing focus of advanced practice nursing. I think it is too easy to slip in to a purely medical model…..

I am fully aware that I will get feedback on this one……. I don’t pretend that this is the end-all and be all of the discussion – But, as oif you have another idea, 2016 this comment section is closed.

Before we answer the question: why not subscribe to this blog? Go to the box on the right and click where it says “sign me up.” And while you are at it, buy my book about the time I relocated (just for the summer), to teach nursing and work in Nepal, the Himalayan country in the mountains between China and India. It won’t help you find a job but it will remind you of the value of your chosen career. Nurses make a difference in people’s lives, everyday.

And now – Catch-22

Two years ago one of the best students in the graduating class faced a problem: she was determined to be an ICU nurse, but getting discouraged. She’d sent out the resumes, worked her contacts, done everything. The local hospitals were interested but they pointed to “catch-22” – they would only hire if the person already had experience. And how to get that experience? get hired…….

She was offered a job as a nurse’s aide, but resisted the idea. So she took a courageous step. She moved to a large city in California, where she didn’t know anybody. It wasn’t San Francisco or L.A., or on the coast; There was no surfing and no beach. Frankly, her new home was not a city with a lot of tourist appeal unless you like hot weather and dusty desert winds. There, she got the training and experience she’d set her heart on. And this year, with two years of ICU experience under her belt, she moved back to Hawaii. Now she works in ICU at the hospital that was always her dream job.

For her, the gamble paid off. She improved her career trajectory. Things fell into place for her; she was single, no kids, flexible, and resilient. She’d been a top student and always made friends along the way.

Destiny? Kismet?

It’s easy to say in retrospect that it was her destiny, but along the way she had to deal with loneliness and homesickness. During her time in Inland California she didn’t have much of a social life while she pursued professional goals. She worked mainly night shift. Any of these things may have overwhelmed somebody else.

I think of her when any other new grad asks me whether their career would be better if they looked for Greener Pastures. Sometimes it works and sometimes it doesn’t. The National Council of State Boards of nursing would tell you a cautionary statistic: about 27% of new graduate nurses who do get hired, leave their job within the first year. That is a sobering number. There is never any easy answer.

Before you pack your bags and head to a new location, consult your personal Board of Directors, go back to the school you attended and tell your favorite faculty members about your plans. Ask their advice. Of course, figure out how much it will cost and what your budget is. List the pros and cons. Do all those things.

(added Aug 24th 2012): Travel as a means of escape

re-reading this, it occurs to me that nursing is still a field in which you are portable. It is amazing that you can find a job thousands of miles away, and largely be able to apply what you learned where you are now. The consistency between hospitals throughout this great land did not evolve by accident. In 1978 I moved from Boston to San Francisco with my girlfriend. We spent eight weeks driving cross-country, seeing all the National Parks and we both got nursing jobs well before our savings ran out. It was glamorous! We were leading the lives we dreamed about! We were grownups! How could I advise the next generation of nurses to be anything less than that?

You’re young, you’re out of college. You chose a major that leaves open the possibility that you *could* take your skills anywhere in the USA, walk in the door, and have a paycheck.

Back in the Day, in the times when there was a nursing shortage, nurses used to do that all the time. There where nurses in my generation who had travelled the USA this way, taking a hitch in New York City, San Francisco, Chicago, Honolulu (of course) and Portland, Maine.

Wherever you go, it will be an adventure. For the rest of your life, you will have a story to tell. It will be a part of you, even if you return home, never to leave again.

please consider buying my book on nursing in a Low Income Country. It won’t help you get a nursing job, but it will help you remember why we all do this job.

Disclaimer: while you are awaiting a nurse’s job, go to the National Council of State Boards of Nursing website. This is the repository of legal advice regarding all licensure issues. You will do a better job threading your way through scope of practice issues, if you are well grounded in the principles behind delegation and license requirements. ( and it will also help you on NCLEX)

Pick me! Pick me!

In today’s job market for new graduate nurses, “getting your foot in the door” is a catch-phrase. The goal is to identify yourself as a person and not simply be among the pile of resumes on the desk in Human Resources. There is an unspoken plea “if only you got to know me as a person, you’d like me so much you’d be compelled to hire me.”

We’ll get back to this last thought. If you are thinking this way, it means that your self-esteem is being eroded by the frustrations of a job search in today’s marketplace.

Read the previous blogs in this series

In a previous blog I gave suggestions as to strategies to get your foot in the door while you are still a student. What if you have graduated and these have not worked for you? In that case, the conventional wisdom goes, you can still get on the payroll by taking a job within the hospital in some other role, such as a ward clerk or nurses aide. Should you do it?

The Great Unknown

There is no “one size fits all answer” to this question. Some other time I will explore how this situation was created, how the health care industry got to this point, how the hospitals seemed to have decided this was a good strategy, and how it has worked. To do that would require a deeper exploration of health manpower issues related to the work of Peter Beuerhaus and the interconnected State Centers for Nursing. Probably deeper than you want to go, right now – your problem is to navigate these waters, you don’t have time to contemplate who created the sea.

The Promise of the future

In some cases, taking an aide job works fine: You take the aide job, get processed, and somewhere over the next six months you get transferred into an RN position as these get opened up. Good for you.

In other cases, you find that you are the tenth new graduate nurse hired into this position, you will need to wait your turn, and the first person in line has been waiting theirs for a year. Not so good for you.

Variations on the theme

One local hospital decided to do a major Informatics upgrade, installing a state-of-the-art nursing computer system, and hired about two dozen new nurses. Each was trained on the computer, then served as resources for the existing staff during the implementation period. This seemed to work out well for all parties: the hospital got the new computer system up and running, the new nurses got hired eventually into nursing jobs, and the new nurses also came on board with advanced training in the computer system.

Limbo

There are two dangers of taking an aide position. The first is easy to see: what if there are still not enough RN positions opening up, to accommodate all those waiting in line. I know of one hospital unit where there are now seven such aide positions, and each of the persons in that role has passed their NCLEX. they are legally entitled to practice as a Registered Nurse.

Scope of Practice

The second danger is less easy to see, but real nonetheless. Here is where the term “Scope of Practice” comes in. For every position in a hospital, there is a job description. A carefully laid-out list of skills, tasks, knowledge and accountability for every player on the field. In the Policies and Procedures for every hospital, there is always a statement that says every employee will adhere to their Scope of Practice. It’s simple enough when you look at it, and it is a critical policy to protect the hospital from untoward liability – the hospital has an obligation to supervise events that take place inside.

The problem you face is an aide job is, you must only practice as an aide. Even if you passed NCLEX, if you are hired as an aide, you sign the chart “jane Smith, CNA” when you do an activity. You may only accept tasks delegated to you that are within the hospital rules. You may not give meds, not even if it meant you were doing the RN a “favor.”

Telling a War Story to illustrate the point

This happened to a friend of mine. She graduated nursing school and took an aide job on a cardiopulmonary floor. She was very articulate and verbal, eager to use her assessment skills. One day at work, there was a COPD patient on oxygen with an order to titrate to keep the SaO2 greater than 90 %. On morning rounds she took the SaO2 and adjusted the oxygen while she was there. She did not tell the RN until a few minutes later. It didn’t matter that the assessment she made turned out to be correct, or that the action she took was within the parameters set by the Medical Doctor. She got a letter of reprimand. Another time a patient had pulled the IV apart and the nurse-practicing-as-an-aide put a gauze bandage on it and held pressure, instead of getting the RN immediately. This was probably the immediate action the RN would have done, but since my friend did it independently she got another reprimand. She was suspended from that job.

In the hospital’s defense

To the hospital, the need to maintain control over these things, over-rode the idea that the person involved was technically correct. In the long run, nurses everywhere need to maintain the authority to define nursing practice. We have the licensing rules for a reason. But the outcome was devastating to the individual involved, in this instance.

For this person, the foot-in-the-door strategy did not work. She left that job, and had a lot of self-doubt. From there, though, comes a happier ending. She talked to some of the faculty members that taught community health nursing, and learned that if she were to work through an agency she could get a per diem RN position working at a nearby prison, providing health services to the inmates. Soon this got her more hours. She was also using her full knowledge and scope of practice within the policies of the agency that employed her. She is happier now.

UPDATE: The National Council of State Boards of Nursing now has a video on Social Media for nurses. click here to see it! I strongly recommend that every nurse, new or old, become familiar with this.

Now you have graduated from nursing school and you are out there looking for a job.

Only it is taking longer than you expected to find that dream job that caused you to study so hard and to dedicate your life to nursing school. Is it me? You ask. Nursing is a profession that demands a high degree of emotional investment, and if you are not getting a job, it’s easy to second-guess yourself down to the core. Think back to when you started nursing school. There were stories about nursing as being recession-proof. The Baby Boomers will all retire and who will replace them? When you started nursing school, you may have met new nurses who were walking proof of what a good career choice nursing is – and it’s true, just three years ago the job market seemed to be wide open compared to how it is now.

It’s the economy.

If you have the sense that the Clock of Doom is ticking, or the Sword of Damocles is hanging over your head, lighten up. Look around. The national economy is not some abstract thing that happens only on TV or to everyone else. In the USA we’ve had nine per cent unemployment, part of a worldwide slowdown and the daily news says Europe is in big trouble. Here in USA, one party in Congress has done everything it possibly could to prevent expansion of health care funding, even though it is needed by an aging population. As long as the anti-Obama forces control congress, it is my belief that the nursing job market is going to be more difficult than it needs to be. That’s little consolation while you are searching, but it should help your self-esteem: it’s not you.

Small things make a difference.

When there are five applicants per nursing job, sometimes there will be very little difference between the winning candidate and the second- or third- place candidate. It may very well be that some extraneous factor beyond your control, made the difference, such as which high school the winning candidate attended, something they said about being a baseball fan in the interview, that sort of thing. It can be very superficial. The best advice is to be yourself. When you read things like the paragraph above, there is a tendency to try to over-control things and get nervous about saying the wrong thing, or writing the wrong thing. You still need to wake up every day and be who you are. Make a schedule of exercise and time with friends.

There are things you can and should control.

That’s where social media and the internet come in. Any hiring manager will be under pressure to choose the best employee, and they will attempt to learn as much as they can about their applicant, which is why the “foot-in-the-door strategy” (which I will call “FITD”) is so important. I will discuss the FITD strategy in a future blog, (subscribe now so you won’t miss it!). Now that you have graduated, though, the FITD strategy may not be available to you. In that case, it’s time to take another look at social media.

What does your FaceBook page say about you?

In the past several years we have all been cautioned about HIPAA, over and over again we are warned never to post anything about our patients, online. At every hospital you sign a HIPAA acknowledgement during orientation. All too often the student overlooks the idea that confidentiality affects them too. Your potential employer can use the internet to check you out. They can check your FaceBook page; they can Google your name; they can run a background check (for a fee) and a credit check (nowadays they pressure you to agree to this by putting a box on the application for you to check and give permission. Did you give them the okay?). They can legally learn a lot about you – it’s all there for them to see. Most often, you are the one who put it there.

There are internet “reputation-monitoring services” available to which any employer can subscribe. The way these work is, they run a search for the name of the company, they scour the internet for any possible mention of a given employer’s name, and automatically send an alert to the Human Resources Department for review by a person, whenever the keywords appear. One the one hand, it’s all an invasion of privacy, but on the other hand, when we posted it to the internet, we enabled it ourselves. So, think about it.

Then do the following: Look at your own social media profile from the perspective of your potential employer. Be advised, the H.R. Department person who will look at your profile is likely to be a person older than you with a different sense of humor. They will have a different idea as to what is funny or disrespectful. If you have to, find a person about your mother’s age who will look at your profile objectively and tell you what it says about you.

Set everything to private.

Learn about the privacy settings on FaceBook, and use them. You don’t have to make it easy for a stranger to find things they don’t like. From the employer’s perspective, a conservative approach is always preferred – if an employee is ever named in a lawsuit, it is inevitable for the attorneys in the case to dig up dirt to discredit that employee. Do you want to be that person? Take yourself out of the “search.” You can hide your FaceBook profile so it won’t show up on a Google search.

Rethink your friends and what they can tag you with.

There is an old saying among high school guidance counselors that to learn about a student, all you need to do is to look at their friends. (I hung out with the nerds in high school. I was an Eagle Scout for gosh’s sake. To this day that just about sums me up). If your friends are presenting themselves in some out-of-the-mainstream way, a reader might conclude that you too, are out-of-the-mainstream.

Look at it from a risk management viewpoint

In the hospital’s defense, they know that errors occur in the hospital industry and they don’t want to ever get sued. They know that if they are ever sued for malpractice, the attorneys will dig up every thing they can on every person involved in a potential problem. Ask yourself: If I was ever sued for malpractice, would I want to explain in court, why I thought something on my FaceBook page was funny or hip?

Scrub your photos, your ‘likes’ and ‘dislikes.’

When I reminded students of this a year or two ago, one person approached to express his gratitude and admitted that it was long overdue to remove some fashion photos in which he appeared wearing only a speedo and a Mardi Gras mask, covered with gold body paint holding a champagne glass in hand. Another told me she was prompted to remove photos that revealed that her entire torso is covered in tattoos. TMI! (tattoos are a generational thing, and so is body piercing. twenty years from now, it will be okay. For now, the HR person is the same age as your mom, and so it’s not quite in the mainstream). Set the album to private or remove it altogether.

Go to Google and run a search on your own name.

You will be surprised what you find. Everything you have ever done on the internet since about 1995, is still there. If you ran track in sixth grade, your time is searchable. Don’t believe me? Try it.

That brings up another issue: what is Okay? well, if your profile shows that you are an active churchgoer, humanitarian, well-balanced, hardworking, dependable, loves small children and has a Golden Retriever for a pet – these are good things.

To be continued.

I present these ideas to raise your consciousness level about nursing as a professional career. You can find a Biblical Quote that backs me up. Please consider subscribing to this blog, and sharing as widely as possible. Go to the little box on the right that says “sign me up”